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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:56:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240820094929
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 53DATE:
01/31/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Latrice RossTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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resident was not bathed per service agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Greenhaven Estates RCFE on 1/31/25 at 9:20am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Licensee, Latrice Ross and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegation is unsubstantiated. LPA condcuted interviews with R1 who denied requesting an alternative location to shower in. Staff identified as responsible for bathing R1 offered to provide and assist with showers while the resident's hot water was not working which was declined by R1. This information was also confirmed by R1. R1 did provide statements she performed bed baths while waiting for her in room hot water to be restored.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20240820094929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
VISIT DATE: 01/31/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of supervision and personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240820094929

FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 53DATE:
01/31/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Latrice RossTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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staff are not responding to call lights in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Greenhaven Estates RCFE on 1/31/25 at 9:20am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Licensee, Latrice Ross and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA conducted interviews with 9 residents and six staff members. All residents interviewed identified delays in staff responses after requesting assistance with their alert buttons or in room pull cords. Five of the six staff members interviewed identified delays in responding to call lights with their current duties and staff schedules. None of the identified delays resulted in serious injury for any residents present per interviews and file reviews.

report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240820094929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
VISIT DATE: 01/31/2025
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240820094929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by statements obtained from staff members, and residents
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Administrator has agreed to complete and incorporate additional documentation of all calls for assistance and document the responding staff member and when they arrive to assist resident and when it is completed. Facility is also evaluating additional technologies that may assist in speedier reaction times as well as adressing staff inadequacies.
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that facility has delays in response to calls for service which resulted in resident's needs not being met in a timely manner such as falls or general assistance.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5